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1、 非瓣膜性房颤论文：非瓣膜性房颤患者纤溶因素的变化及非瓣膜性房颤论文：非瓣膜性房颤患者纤溶因素的变化及抗凝治疗的影响抗凝治疗的影响【中文摘要】监测非瓣膜性房颤患者 PAI-1 和 D-dimer 的浓度,并观察 PAI-1 和 D-dimer 浓度随抗凝治疗的变化情况,分析影响PAI-1 和 D-dimer 水平的临床因素,探讨纤溶因素在非瓣膜性房颤患者高凝状态形成中的作用及抗凝治疗早期纤溶指标浓度的变化趋势,以期能够更深入地做好高危人群的筛查及抗凝治疗监测等方面的工作。方法：选取自 2009 年 2 月至 2010 年 2 月来我院心内科专科门诊就诊的高血压患者,同时还有以下一项或多项危险因
2、素的非瓣膜性房颤患者(年龄75 岁,既往脑卒中或栓塞病史、糖尿病)25 例作为华法林抗凝治疗组,并选取患有高血压疾病的窦律组患者 27 例作为对照组。监测窦律组,房颤组患者抗凝治疗各时间点(1 天、1 月、2月)的血常规、肝肾功能、血脂、血糖等实验室指标,应用酶联免疫吸附法分别测定窦律组及房颤组患者抗凝治疗各时间点(1 天、7 天、1 月、2 月)PAI-1、D-dimer 浓度和 INR 值。分析两组患者 PAI-1 和D-dimer 浓度的差异、影响 PAI-1 和 D-dimer 浓度的临床因素、该指标随抗凝治疗时间的变化趋势及 PAI-1、D-dimer 和 INR 三者之间的相关性。
3、结果：1.房颤组和窦律组在实验室基线资料上无差别,年龄因素在两组之间不均衡,多因素分析发现年龄和 PAI-1、D-dimer水平无关。房颤组 PAI-1 和 D-dimer 水平均明显高于窦律组。2.对房颤组 PAI-1 和 D-dimer 浓度随抗凝治疗时间各点(1 天、7 天、1月、2 月)的变化值资料行单因素重复测量方差分析。PAI-1 和 D-dimer 浓度在各时间点相比具有显著统计学差异(p 分别为0.000,0.000)；PAI-1 浓度随抗凝治疗各时间点下降百分比分别为7%、18%、31%, D-dimer 浓度下降百分比分别为 19%、34%、43%；行事后两两检验,PAI-
4、1 浓度在第 1 天和 7 天相比差异性无统计学意义(P),余各两个时间点之间的差异性均有统计学意义。D-dimer浓度在各两个时间点之间的差异性均有统计学意义。3.分析房颤组PAI-1、D-dimer 抗凝治疗各时间点的浓度和窦律组之间的差异性。PAI-1 浓度在抗凝治疗 7 天时与窦律组相比较无差别(p0.05),余时间点(1 月、2 月)均有差别(p0.05),余时间点(7 天、1 月)均有差别(p2.0)之间的差异性有统计学差异(p 值分别为 0.030、0.038),INR2.0 组 PAI-1 和 D-dimer 均值较高。简单相关分析发现 PAI-1、D-dimer 和 INR
5、之间均呈显著负相关(r 值分别为-0.263、-0.443；p 值分别为 0.010、0.000),PAI-1 和 D-dimer 之间呈显著正相关(r=0.468P=0.000)6.全部患者在抗凝治疗随访期间无脑卒中和周围血管血栓并发症发生,无胃肠道不适及出血等不良反应。结论：1。非瓣膜性房颤患者存在纤溶相关指标(PAI-1、D-dimer)水平明显升高,提示低纤溶状态是其高凝状态形成的重要原因。2.PAI-1 和 D-dimer 水平是房颤患者高凝状态的独立危险因素,通过监测 PAI-1 和D-dimer 的水平可早期预测其血栓的发生。3.吸烟、既往血栓栓塞、糖尿病和冠心病危险因素可能通过
6、影响非瓣膜性房颤患者 PAI-1 和D-dimer 活性而导致纤溶活性降低,促进房颤的高凝状态及血栓形成。4.抗凝治疗可使非瓣膜性房颤患者的纤溶活性得到逐步改善,治疗 1周纤溶活性即可得到明显改善,PAI-1、D-dimer 分别在抗凝治疗第7 天、2 月时即可降至高血压窦律组患者的水平,抗凝治疗可有效快速改善房颤患者的低纤溶状态。5.随抗凝治疗密度的加强,房颤的纤溶活性可得以改善,在临床上联合 INR 和 PAI-1 或 D-dimer,或联合两者可以对房颤患者高凝状态及其改善情况进行更全面的监测。【英文摘要】s:The aims of the study were to observe P
7、AI-1 and D-dimer levels in NVAF patients, investigate the variation tendency of PAI-1 and D-dimer leves along with the anticoagulant therapy, analyze the clinical factors affecting PAI-1 and D-dimer levels, and explicit the role of fibrinolysis system in the formation of hypercoagulable state with N
8、VAF patients, We anticipated this research may provide further study in screening high risk populations and monitoring the safety of anticoagulant therapy in NVAF.Methods:There were two groups in this study, group 1:NVAF patients (n=25)with one or several risk factors(except for hypertension): age75
9、, history of stroke or thromboembolism, diabetes mellitus; group 2:Sinus rhythm group with hypertension as control group. ELISA method was used to detect the plasm levels of PAI-1 and D-dimer in the two groups. The difference of PAI-1, D-dimer levels in two groups and the clinical factors affecting
10、PAI-1 and D-dimer levels, the variation tendency of the two indexs along with anticoagulant therapy, and the correlation among PAI-1, D-dimer and INR were analyzed.Results:1. In the two groups, there was no difference in the laboratory basic information, age was imbalanced in the two groups, but mul
11、tivariate analysis found age had no association with PAI-1 or D-dimer levels. The levels of PAI-1 and D-dimer in AF group were higher than that in control group.2. Colleting the data of PAI-1 and D-dimer levels at all anticoagulant therapy time points (the 1st day,7th day,1st month,2nd month) in NVA
12、F group, The plasm levels of PAI-1 and D-dimer had significant changes in each time points (p=0.000, p=0.000). The decreased percentage of PAI-1 concentration were 7%,18%,31%, respectively; for D-dimer were 19%、34%、43%. No difference was found for PAI-1 leval in AF group at two time points (the 1st
13、day,7th day). The variation of D-dimer levels had significant difference at each two time points.3. The variation of PAI-1 level had no difference between control group and AF group (the 7th days) (p0.05), difference was found between control group and AF group (the 1st month,2nd month) (p0.05), dif
14、ference was found between control group and AF group (the 7th days,1st month).4. Analyzing the clinical factors affecting PAI-1 and D-dimer levels. PAI-1 level was higher in the patients with history of cigarette smoking, thromoembolism, coronary heart disease than those who didnt have these risk fa
15、ctors, PAI-1 was correlated with history of cigarette smoking, thromoembolism, coronary heart disease (rs were 0.233,0.302,0.306, respectively)(P2.0). PAI-1 and D-dimer levels were higher in INR2.0 group. PAI-1, D-dimer and INR level were negatively correlated, respectively(r were-0.263,-0.443; p we
16、re 0.010,0.000. respectively), while PAI-1 and D-dimer were positively correlated (r=0.468, P=0.000)6. During the study period, all the patients had no side effects such as stroke, Peripheral vascular thrombosis, gastrointestinal discomfort or bleeding.Conclusions:1. PAI-1 and D-dimer levels were markedly increased in NVAF patients, low fibrinolysis state is a important factor in the formation of hypercoagulable state in NVAF.
